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Huntington, NY 11743
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Symptoms Assessment




Instructions - Please Read

1. Enter all personal data including a valid email address.

2. Check off all symptoms that apply regularly, such as daily, weekly. or monthly.

3. Click the "Submit button" at the bottom of the form.

4. Your results will be sent to your email address. Be sure to check your email junk mailbox.


Personal Data

Patient Name
Street Address
City
State
Zip Code
Area Code and Phone Number
Email Address
Occupation
Referred by

Sex (m or f)
Age

Height: (feet) (inches)
Weight (pounds)
Height (cm)
Weight (kg)

Number of Bowel Movements per Week (1 number only)

Exercise Level (Choose only one)
1. Little to no exercise
2. Light exercise (1-3 days per week)
3. Moderate exercise (3-5 days per week)
4. Heavy exercise (6-7 days per week)
5. Very heavy exercise (twice per day, extra heavy workouts)


Questions

Check all Symptoms and Questions Below That Apply - They should repeat regularly (daily or weekly)

11. Get boils or sty's more than once per year
12. Throat infections more than once per year (sore throat)
13. Cold sores, fever blisters more than once per year
14. Any infection with fever more than once per year
15. Swollen lymph glands more than once per year
16. Ear infections more than once per year
17. Slow to recover from cold or flu
18. Catch colds or flu easily
19. Lacerations (cuts) become infected easily
20. Itchy nose
21. Itchy eyes
22. Itchy roof of mouth or throat
23. Clear watery nasal discharge
24. Headaches
25. Mucous in the throat
26. Post nasal drip
27. Discharge from the eyes
28. Puffiness under the eyes
29. Ear discharge or stuffed up
30. Nasal congestion
31. Running nose
32. Wheezing
33. Sneezing
34. Fatigue
35. Exposed to cigarette smoke
36. Exposed to mold
37. Sinus congestion
38. Food allergies or sensitivities
39. Skin rashes
40. Entire body aches, painful to touch
41. Swollen joints
42. Certain foods make you sick, nauseous, depressed, jittery
43. Painful stomach or intestine
44. Alternating constipation and diarrhea
45. Swollen or itchy tongue or mouth
46. Difficulty in swallowing
47. Hyperactivity
48. Fatigue increases after eating
49. Exposed to chemicals or radiation at work
50. Eat luncheon meats containing nitrates or nitrites
51. Eat fruits and vegetables that contain pesticides
52. Eat foods that contain monosodium glutamate (MSG)
53. Use artificial sweeteners regularly
54. Milk makes allergy symptoms worse
55. Pain in chest and left arm
56. Calf muscles cramp while walking
57. Heart palpitations
58. Feel jittery
59. Irregular heart beats
60. Swelling of feet and ankles
61. Fast heart beat
62. Exhaust with minor exertion
63. Light-headedness
64. General weakness
65. Smoke cigarettes/tobacco
66. Chew tobacco
67. More than 3 cups of coffee daily
68. High daily stress level
69. Cold hands and feet
70. Tingling or burning in hands and feet
71. Numbness in extremities
72. Skin sores of the legs or feet
73. Spider veins on nose or face
74. Ringing in ears
75. Poor concentration
76. Slurred speech
77. Salt foods without tasting
78. Exercise regularly with low to moderate exertion
79. Exercise regularly with high exertion (Aerobics)
80. Vascular surgery
81. Chest pain without left arm pain
82. Tightness or pressure in the chest
83. Upper chest or neck itch
84. Chronic cough
85. Difficulty in breathing
86. Shortness of breath
87. Sensitive to smog / air pollution
88. Infections settle in lungs
89. Respiratory attacks that last hours to days
90. Bleeding gums or periodontal disease
91. Stomach pains after meals
92. Nausea
93. Dependency on antacids
94. Butterfly sensations in stomach
95. Difficulty in belching
96. Stomach pain when emotionally upset
97. Sudden, acute indigestion
98. Relief of stomach pain by drinking carbonated beverages
99. Relief of stomach pain by drinking cream or milk
100. History of ulcer or gastritis
101. Current ulcer or gastritis
102. Black stool while not taking iron supplements
103. Nervousness
104. White spots or lines on finger nails
105. Indigestion 1-3 hours after eating
106. Diarrhea
107. Roughage and fiber causes constipation
108. Mucous in the stools
109. Stool poorly formed
110. Shiny stool
111. Three or more large bowel movements daily
112. Foul smelling stool
113. Dry skin or dry hair
114. Pain in left side of rib cage
115. Acne
116. Difficulty gaining weight
117. Dizziness when standing suddenly
118. Loss of vision when standing suddenly
119. Crave sweets
120. Crave carbohydrates
121. Headaches relieved by eating sweets or alcohol
122. Impatient
123. Moody
124. Irritable if a meal is missed
125. Wake up in middle of the night craving sweets
126. Poor memory
127. Feel faint
128. Calmer after eating
129. Frequent urination
130. Night sweats
131. Increased thirst
132. Lowered resistance to wound infection
133. Leg sores
134. Poor wound healing
135. Feel energized from exercise
136. Failing eyesight
137. Crave sweets, but eating sweets does not relieve symptoms
138. Family history of diabetes
139. Glucose (sugar) in urine
140. Elevated blood glucose (sugar)
141. Toe and fingernail fungus
142. History of antibiotic use
143. Anemic or recent history of anemia
144. Itchy skin
145. Itchy between toes and fingers
146. Abdominal bloating
147. Intestinal gas
148. Chemical sensitivities
149. Depression
150. Crave sweets and yeast containing foods
151. Bladder and kidney infections
152. Dark colored stool
153. Do not eat high fiber foods daily
154. Less than 7 bowel movements per week
155. More than 2 bowel movements per day
156. Bowel movements are irregular
157. Abdominal pain on right or left side
158. Abdominal pain relieved by a bowel movement
159. Abdominal pain is triggered by eating
160. Yellowish conjunctiva (white part of the eyes)
161. Pain radiates along outside of leg
162. Intolerance to greasy foods
163. Headaches after eating
164. Dark urine
165. Light colored stool
166. Hard stool
167. Gray colored skin
168. Pain in right side under rib cage
169. Big toe painful
170. Don't eat regular balanced meals
171. Don't get enough to eat
172. More than 10 beers/week
173. More than 10 ounces of alcohol/week
174. Eat candy regularly
175. Drink soda pop regularly
176. Eat at fast food restaurants regularly
177. Eat fried foods regularly
178. Use refined sugars regularly
179. Diet often
180. Hair loss
181. Dry skin
182. Bones protrude
183. Don't use vitamins and minerals regularly
184. Use very large-doses of vitamins and/or minerals regularly
185. Neurological disorders
186. Sore or burning tongue
187. Lower back pains
188. Poor night vision
189. Confusion
190. Sore or sensitive gums
191. Leg pain or cramps
192. Pain in feet
193. Some alcohol use regularly
194. High stress levels effect stomach
195. Lack of appetite
196. Dizziness
197. Inflamed corners of the mouth
198. Steeply curved nails
199. Exposed to lead in the air or water
200. Sensitivity to light
201. Sensitive to the cold
202. Weight gain
203. Change in personality
204. Loss of temper or irritable
205. Enlarged neck
206. Trouble waking up in the morning
207. Low sex drive
208. Swollen (bulging) eyes
209. Warm, moist skin
210. Tremors
211. Increased activity
212. Increased appetite
213. Weight loss
214. Insomnia
215. Diffuse tanning on exposed and unexposed portions of the body
216. Black freckles over the forehead, face, neck, and shoulders
217. Mood swings
218. Dark circles under the eyes
219. Slender fingers and extremities
220. Purple streak or line on the abdomen
221. Kidney stones
222. Osteoporosis
223. Emotional disturbances
224. Simultaneous inflammation in multiple joints
225. Simultaneous pain in multiple joints
226. Stiffness lasting more than 30 minutes on arising in mornings
227. Stiffness lasting more than 30 minutes after prolonged activity
228. Deformation of joints
229. Joints lock with movement
230. Early afternoon sleepiness
231. Skin nodules
232. Deep aching pain in bones, particularly the back
233. Pain increases when weight is applied
234. Vertebrae crush fractures
235. Bone fractures
236. Bones fracture easily
237. Pain in the extremities
238. Burning sensation in the extremities
239. Weakness in the extremities
240. Frequent tooth decay
242. Throbbing pain on one side or front and rear of head
318. Pain on one side or front and rear of head
319. Pain in the forehead only
243. Headache preceded by a short period of depression, irritability, or restlessness
244. Headache preceded by visual flashing zig-zag lines
245. Headache preceded by other visual disturbances
246. Visual disturbances disappear shortly after headache begins
247. Nausea associated with headache
248. Sensitive to light, especially during headache
249. Sensitive to noise, especially during headache
250. Extremities are cold before and during headache
251. Family history of migraine
252. Difficulty with speech before headache
253. Intensity of headache increases when lying down
254. Often prefer seclusion
255. Frequent urinary infections
256. Rarely need to urinate
257. Urinate when you cough or sneeze
258. Painful or burning urination
259. Difficult urination's
260. Dripping after urination
261. Can not hold urine
262. Rose colored (bloody) urine
263. Cloudy urine
264. Strong smelling urine
265. Back or leg pains associated with dripping after urination
266. History of kidney or bladder infections
267. Back pain in the kidney area
268. General water retention
312. Drug / Medication addiction
313. Must repeat actions constantly
314. Making decisions is difficult
315. Constant flow of speech
316. Obsessed fear of danger
(Previous Tests)
317. Previously Diagnosed Diabetic Type 1
323. Previously Diagnosed Diabetic Type 2
321. Previously Diagnosed Migraine
322. Previously Diagnosed Hypothyroidism
320. Previously Diagnosed with high Cholesterol
324. I'm an Athlete
(For males only)
269. A sense of bladder fullness
270. Increased straining with smaller and smaller amounts of urine
271. Wake up at night to urinate
272. Pain or fatigue in the legs or back
273. Ejaculation causes pain
274. Difficulty attaining and/or maintaining an erection
275. Premature ejaculation
276. Pain/coldness in genital area
277. Infertile
278. Varicose veins on scrotum
279. Low sperm count
280. History of venereal disease
(For females only)
281. Vaginal yeast infections
282. History of oral birth control
283. Heavy menstrual flow
284. Prolonged menstruation
285. Short menstruation
286. Menstrual irregularities
287. Monthly weight gain
288. Moodiness and irritability before menstruation
289. Change in appetite before menstruation
290. Suicidal feeling before menstruation
291. Anxiety or anger before menstruation
292. Breast fullness and pain before menstruation
293. Leg cramps and tenderness before menstruation
294. Asthma attacks before menstruation
295. Bruise easily before menstruation
296. Respiratory allergies worsen before menstruation
297. Visual disturbances worsen before menstruation
298. Dull ache radiating to low back or legs
299. Abdominal pains subsides after several days
300. Pelvic soreness
301. Have to lie down on first or second days of period
302. Clots are expelled during menstruation
303. Hot flashes
305. Menopause or Hysterectomy
306. Heavy bleeding two weeks/month
307. Sweating throughout the day
308. Dryness of skin, hair, and vagina
309. Painful intercourse
310. Vaginal pain
311. Vaginal itching